COMBINATION SYNDROME !

BY: Dr.PAWANJ EET

SI NGH CHAWLA
RAMA DENTAL COLLEGE,
HOSPI TAL, KANPUR
GUI DED BY:
Dr. RAJASHEKAR SANGUR
Dr. LAKSHMANA RAO
Dr. PRADEEP
Dr. TANU MAHAJAN
Dr. RAJIV
Combination Syndrome
Combination syndrome, first identified by Kelly in 1972, is found in patients
wearing a complete maxillary denture, opposing a mandibular distal
extension prosthesis.
The group of complications occurring in these patients are interlinked to one
another and collectively represent a syndrome
The glossary of Prosthodontic terms, defines Combination
Syndrome as: the characteristic features that occur when
an edentulous maxilla is opposed by natural mandibular
anterior teeth, including loss of bone from the anterior
portion of the maxillary ridge, overgrowth of the
tuberosities, papillary hyperplasia of the hard palatal
mucosa, extrusion of mandibular anterior teeth and loss of
alveolar bone and ridge height beneath the mandibular
removable partial denture bases, also called anterior
hyper function syndrome



1.Loss of vertical
dimension of occlusion.

2. Occlusal plane
discrepancy.

3. Anterior spatial
repositioning of the
mandible.


Ellsworth Kelly was the first person to use the term
Combination Syndrome


4. Poor adaptation of the
prostheses.


5. Epulis fissuratum.


6. Periodontal changes.



1. Loss of bone from the anterior part of the maxillary
ridge.

2. Overgrowth of the tuberosities

3. Papillary hyperplasia in the hard palate.

4. Extrusion of the lower anterior teeth.

5. The loss of bone under the partial denture bases.




Fibrous anterior
segment of maxilla


Occlusal discrepancy



Extrusion of lower
anteriors

Potential Changes In Combination
Syndrome
Additional Changes
Classification of combination syndrome
CLASS I :

Completely edentulous
alveolar ridge

Maxilla

Mandible

Modification- 1 (M1)

Partially edentulous ridge
with
preserved anterior teeth only

Modification- 2(M2)
Stable fixed full Dentition
(natural teeth or implant
supported crowns/bridges)

Modification-3(M3)
Partially edentulous ridge
with preserved teeth
anteriorly and one in the
posterior region

Class 2

Partially edentulous alveolar ridge
with teeth present in both
posterior regions ,edentulous and
atropic anterior region

Maxilla
Mandible
Modification- 1 (M1)

Partially edentulous ridge with
preserved anterior teeth only

Modification- 2(m2)

Stable fixed full dentition

Modification-3(m3)

Partially edentulous ridge with
preserved teeth anteriorly and
one in the posterior region


Class 3
Partially edentulous alveolar ridge with teeth
present in one posterior region only, edentulous
and atropic anterior and one posterior region
Maxilla-
Mandible


Modification- 1 (M1)

Partially edentulous ridge with
preserved anterior teeth only

Modification- 2(M)

Stable fixed full dentition

Modification-3(M3)

Partially edentulous ridge with preserved
teeth anteriorly and one in the posterior
region



A progressive anterior maxillary
bone loss can be seen in cases
of complete maxillary denture
opposed by the distal
extension r.P.D

Similar condition occurs when a
maxillary anterior fixed or an
implant- supported prosthesis
can also lead to the
combination condition
BASED ON THE PATHOGENESIS 4 TREATMENT
POSSIBILITIES CAN BE CONCEPTUALLY APPLIED
1. Properly designed removable
partial denture around stable
mildly super-erupted anterior
teeth opposed by a complete
maxillary denture with even
occlusal stress over hard and
soft tissues and preserve the
posterior occlusion


some cases mandibular
anterior teeth under go
root canal followed by
crowns shortened to place
opposing max incisor in
proper position.

2. Extraction of anterior
mandibular teeth
with /without alveoloplasty
and construction of a complete
upper and lower dentures
with stable posterior occlusion
with punctilious care and
maintenance protocol


3. An implant treatment of the existing dentition with or /without
extraction of teeth to re-establish solid posterior occlusion with implant
assisted or implant supported maxillary or mandibular prosthesis
4. Using advanced bone grafting
techniques to rebuild maxillary
anterior alveolar ridge



The last two seem to be a causative
physiologic surgical prosthetic rehabilitation of the
stomatognathic system that can prevent continuous bone
detoriation and related signs and symptoms in
combination syndrome patients.


The first two treatment modalities are conventional
preimplant symptomatic restorative techniques .
A preservation of the health of the natural dentition
and its masticatory function are the important
keys to prevent progression of the combination
syndrome.




An immediate or early
replacement of lost teeth with
dental implant can be the most
effective treatment options
that can be circumvent the
development of this syndrome



A multidisciplinary
approach is a paramount
to accomplish a complex
task of comprehensive
dental treatment of the
combination syndrome
patients
Thank you